Improving the quality and content of discharge summaries on acute medicine wards: a quality improvement project.

Discharge summaries are important medical documents that summarise a patient's hospital admission. The Royal College of Physicians provides standardised guidance on the content of discharge summaries, given their important role as a handover document to general practitioners (GPs). Our project started in June 2020 on an acute medical ward, where significant variation had been noted in the quality and content of discharge summaries. A multidisciplinary team (MDT) was formed including doctors, nurses and hospital/community pharmacists, as well as a patient representative, to ensure active patient co-design. The problem was scoped by asking GPs to provide feedback via surveys and process mapping. Our aim was to increase the compliance of discharge summaries with 10 core criteria from a baseline of 55% to 95% by June 2021. Change ideas were developed by the MDT and were tested using plan-do-study-act (PDSA) cycles that included additional pharmacy support, a discharge summary template and individualised feedback. The project reached its goal of 95% compliance in January 2021, 5 months ahead of the target date, and this improvement has been sustained since. The project expanded to a second acute medical unit ward in May 2021. The expanded project reached its goal of 90% compliance within 6 weeks and maintained sustained improvement with further PDSA cycles. A standard operating procedure has been created to help embed the changes on these wards. Our future aims are to redesign and improve the current electronic system and to help spread positive changes throughout the Trust.

Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement "Sepsis Six".

BACKGROUND: Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based "Sepsis Six" care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital. METHODS: Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity. RESULTS: Five themes were identified as influencing implementation and guided intervention modification. These were:(1) "knowing what to do and why" (TDF domains knowledge, social/professional role and identity); (2) "risks and benefits" (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle's effectiveness acting as a lever to implementation; (3) "working together" (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) "empowerment and support" (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues' decisions not to implement acting as a barrier; (5) "staffing levels" (environmental context and resources), e.g. shortages of doctors at night preventing implementation. The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions; documents and materials). CONCLUSIONS: This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.